Mv BOUDICCA - The Bahamas Maritime Authority

THE COMMONWEALTH OF THE BAHAMAS
M.v. BOUDICCA
IMO Number 7218395
Official Number 8001101
Report of the investigation into an
Auxiliary Engine Room Fire on the
25th January 2015
The Bahamas conducts marine safety or other
investigations on ships flying the flag of the
Commonwealth of the Bahamas in accordance with
the obligations set forth in International Conventions
to which The Bahamas is a Party. In accordance with
the IMO Casualty Investigation Code, mandated by
International Convention for the Safety of Life at Sea
(SOLAS) Regulation XI-1/6, investigations have the
objective of preventing marine casualties and marine
incidents in the future and do not seek to apportion
blame or determine liability.
It should be noted that the Bahamas Merchant
Shipping Act, Para 170 (2) requires officers of a ship
involved in an accident to answer an Inspector’s
questions fully and truly. If the contents of a report
were subsequently submitted as evidence in court
proceedings relating to an accident this could offend
the principle that a person cannot be required to give
evidence against themselves. The Bahamas Maritime
Authority makes this report available to any
interested individuals, organizations, agencies or
States on the strict understanding that it will not be
used as evidence in any legal proceedings anywhere
in the world.
Date of Issue: 25th July 2016
Bahamas Maritime Authority
120 Old Broad Street
LONDON
EC2N 1AR
United Kingdom
m.v Boudicca – Marine Safety Investigation Report
CONTENTS
1.
Summary
2.
Details of Involved Vessel(s) and Other Matters
3.
Narrative of events
4.
Analysis and discussion
5.
Conclusions
6.
Recommendations
List of Appendices:
I.
Hi-Fog post incident report
II.
Auxiliary Generator Front End Schematic (MaK 6M20
1020kW)
III: Additional photos
THE BAHAMAS MARITIME AUTHORITY
m.v Boudicca – Marine Safety Investigation Report
1
1.1
SUMMARY
The Boudicca sailed from the port of Cadiz, Spain on the 24th January 2015
enroute to the Port of Arrecife, Lanzarote (Canary Islands) with an estimated
time of arrival of 0700 UTC on the 27th January.
Figure 1: Position of Fire off the coast of Morocco
1.2
On the morning of the 25th January at 0324 UTC the fire alarm sounded on the
bridge and in the engine control room indicating a fire had established in the
Auxiliary Engine Room and that auxiliary engine No.1 was ablaze.
1.3
The exact location of the fire was found to be at the forward, starboard side, of
the auxiliary engine No.1. Upon further investigation it was determined that the
fire was initiated by fuel leaking from a broken fuel oil pressure gauge supply
line, igniting on contact with a hot surface in the vicinity of the turbo charger,
resulting in significant damage to auxiliary engines No.1, 2 and 3 and the
surrounding space including cabling, deck head, fixtures and fittings.
1.4
The crew were notified of the fire by two methods. Senior safety critical crew
received, via pager, a transmission “Red Fox” interpreted to mean ‘Code
Bravo’ and via public announcement (PA) initiated by the Officer of the Watch
(OOW) on the bridge. The 4th Engineer in the Engine Control Room (ECR)
reported the fire with the exact location to the OOW prior to commencing
initial actions.
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1.5
Initial actions were in accordance with emergency response procedures and
conducted to good effect by utilizing Marioff Hi-fog fixed firefighting system.
As a result the fire was confirmed as extinguished by 0433. Propulsion and
auxiliary power was subsequently restored by 0725 thereafter and the vessel
diverted its destination to the Port of Tenerife, Spain arriving on the 27th
January at 1856 UTC.
1.6
As a direct result of the damage sustained due to the fire, multiple services were
affected. Propulsion and primary power generation to all services was rendered
temporarily out of action while some nonessential services were rendered out of
action until shore side support could be provided.
1.7
A list was determined shortly after the fire had been extinguished by
approximately 5° to port. This provoked an investigation to establish the root
cause that was later determined to be associated with the significant quantity of
water as a result of the firefighting effort. After further investigation it was
determined that the Hi-fog had continued to function due to a system override
allowing one compartment within the machinery space to flood.
***
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Figure 2: General Arrangement Plan
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2
DETAILS OF INVOLVED VESSEL(s) AND
OTHER MATTERS
2.1.1
The Boudicca is a purpose built passenger vessel owned by Boudicca Cruise
Ltd of London, UK and managed by Fred Olsen Cruise Lines of Ipswich, UK
and registered in the port of Nassau, Bahamas. The principal details as at 1st
June 2015 are as follows:
IMO Number
7218395
Keel Laid
1971
Builders
Oy Wartsila Ab Shipyard, Finland
Gross Tonnage
28,551 tonnes
Nett Tonnage
11,714 tonnes
Length (overall)
206.96 metres
Length (bpp)
175.10 metres
Breadth
25.10 metres
Depth
13.67 metres
Class Society
Det Norske Veritas
Class Notation
1A1 Passenger Ship (unrestricted sea-going
service)
Propulsion
4 x MAN B&W 7L32/40 diesel engines
driving 2 x CP propellers
Auxiliary Generators
3 x MaK 6M20 1020kW, 2 x Wartsila 824TS,
1 x Wartsila 6R 32 BC
Shaft Power
14,000kW
Service Speed
18.5 kts
2.1.2
The vessel is designed and certified for the carriage of one thousand and three
hundred (1,300) persons of which nine hundred and sixty (960) are passengers.
At the time of the incident the vessel was at 88% capacity with 784 passengers
and 356 crew on board.
2.1.3
The Boudicca has seven generators installed; five are located in the auxiliary
engine room on deck 1, zone 4 (AE1 – AE6, AE5 was removed from the
vessel). The auxiliary engine No. 7 (AE7) is located in the casing and
ventilation space on deck 1 in zone 3. The emergency generator is located on
deck 8 port side in zone 4. Additionally the vessel has three fire pumps of
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which one is the emergency fire pump; these are situated on the tank top in
pump room No. 2 (emergency fire pump) zone 2, pump room No. 3 zone 2 and
the main engine room, port side, zone 4.
2.2
Vessel Certification
2.2.1
At the time of the incident the vessel was classed with DNV-GL and all
statutory certificates remained valid.
Primary Certificates:
Certificate of Class
International Tonnage Certificate
International Load Line Certificate
Passenger Ship Safety Certificate
Safety Management Certificate
Document of Compliance
Maritime Labour Certificate
Safe Manning Document
issued
issued
issued
issued
issued
issued
issued
issued
28 Apr 2011
14 Jan 2011
11 Mar 2011
27 Jun 2014
07 Jun 2011
07 Nov 2014
08 Aug 2013
01 Jul 2013
expiry 12 Feb 2016
expiry
expiry 19 Feb 2016
expiry 19 Feb 2015
expiry 17 May 2016
expiry 19 Oct 2019
expiry 22 Jun 2018
expiry 30 Jun 2018
2.3
Port State and Flag State Inspections
2.3.1
The last Port State Control (Paris-MoU) inspection was carried out by MCA in
Liverpool, UK on the 05th January 2015 with no deficiencies recorded.
2.3.2
The last Bahamas Annual Safety Inspection (ASI) was carried out on the 27th
March 2014 in Tenerife, Spain with no deficiencies recorded.
2.4
Weather
2.4.1
At the time of the incident an area of high pressure existed in the proximity of
the vessel, resulting in moderate to slight conditions with a North Easterly
breeze of between 11-16kts, Beaufort scale 4, and a sea state of 3-4, providing a
NE swell of between 1-1.5m.
2.5
Duty Watchkeepers
2.5.1
The following watch team members were on watch in their respective locations
between the hours of midnight to 0400:
Bridge Watchkeepers
Third Officer (OOW) – Joined Fred Olsen Cruise Lines as a Deck Cadet in
2012, promoted to Officer in Charge of a Navigation Watch upon obtaining his
Certificate of Competency (Seafarer Training Certificate in Watchkeeping
(STCW II/1)) in 2014.
Ordinary Seaman (Lookout) – Joined Fred Olsen Cruise Lines in 2005 and had
served as an Ordinary Seaman (STCW II/4) since 2014.
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Engine Watchkeepers
Fourth Engineer (EOOW) – Joined Fred Olsen Cruise Lines in 2007, promoted
to Officer in Charge of Engineering Watch upon obtaining his Certificate of
Competency (STCW III/1) in 2014.
Motorman – Joined Fred Olsen Cruise Lines in 2008 and had served as a Rating
forming part of an engineering watch (STCW III/4) since 2013, becoming a
Motorman in 2014.
Oiler – Joined Fred Olsen Cruise Lines in 2011 and had served as a Rating
forming part of an engineering watch (III/4) since 2013, becoming a Oiler in
2014.
2.6
Fatigue
2.6.1
All watchkeepers on duty during the midnight to 0400 watch, were in
compliance with the statutory hours of rest requirements1. The vessel uses the
Fidelio Time and Attendance computer system to record the hours of rest for all
crew members, the hours of rest records were found to be satisfactory.
2.7
Substance Abuse
2.7.1
Although no alcohol testing was carried out following the incident. There was
no evidence to suggest that substance abuse was a contributory factor.
2.8
Emergency Organisation - Code Bravo
2.8.1
Code Bravo is a code name used to indicate a fire on board. In the event of an
engine room fire the engineer on duty and the motorman on duty is despatched
to investigate the nature of the incident. Once the Code Bravo is confirmed, the
following teams are mustered as per the Emergency Procedures Manual and
assembled at their designated locations:
1
2
3
4
5
Central Command Team
On Scene Command Team
Area Control Team
Rapid response Team
Fire Teams
Location: bridge
Location: scene of incident
Location: scene of incident
Location: scene of incident
Location: various
2.9
Hi Fog System
2.9.1
The Marioff Hi-Fog fire extinguishing system uses water under high pressure,
through specially designed spray heads that cause the water to enter the space at
high speed as a fine fog (mist). The small droplets yield a very large total water
surface area, providing efficient cooling of the fire and surrounding gases.
1
Required by the International Convention of Standards of Training, Certification and Watchkeeping for
Seafarers. 1978 as amended (STCW) and the Maritime Labour Convention, 2006 (MLC 2006)
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3
NARRATIVE OF EVENTS
3.1
All times noted in this report are given in the style of the standard 24-hour
clock without additional annotations. The vessel time used on board at the time
of the incident was Universal Coordinated Time (UTC). The vessel’s time
having been retarded 1 hour at 0200 (UTC+1) that morning to 0100 UTC.
3.2
Arrival and Departure Cadiz
3.2.1
At 2300 on the 23rd January the auxiliary engine No.12 (AE1) was stopped in
advance of the vessel’s arrival in Cadiz, Spain, in order to allow sufficient time
for the engine to cool down in preparation for the following day´s 30,000 hour
scheduled maintenance. The previous service of AE1 had been carried out on
19th August 2013 at 69,812 hours.
3.2.2
During the vessel´s stay in the Port of Cadiz, Spain on the 24th January, the
AE1 was maintained by the 2nd Engineer (2/E) and included overhaul of the
injector valves. On completion the covers were replaced and the engine was
started and found to be working satisfactorily.
3.2.3
The vessel departed the port of Cadiz, Spain at 1930 on the 24th January, having
completed bunkering at 1817; with a total complement on board of 1,140
persons, made up of 784 passengers and 356 crew. On departure the vessel’s
draft was recorded as 7.09m forward and 7.21m aft.
3.2.4
The vessel was destined for the port of Arrecife, Canary Islands. Her estimated
time of arrival (ETA) at Arrecife was 0700 on the morning of 26th January. In
order to meet her arrival time the vessel had to make an average speed of 16kts.
At the time of the incident, the vessel’s speed was 18.5kts operating all four
engines at 95% load.
3.3
Fire in Engine Room
3.3.1
The midnight to 0400 watch consisted of 4th engineer (4/E), motorman and
oiler, who spent the watch monitoring the safe operation of the engine room
and ancillary equipment, the 4/E being the Officer in charge.
2
Auxiliary engine – Generator No.1 (AE1)
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Figure 3: Position of vessel, when Fire Alarm activated.
3.3.2
At 0324 on the morning of Sunday 25th January, the vessel was approximately
50nm North West of Casablanca, Morocco in position 34° 31’.2N 008° 12’.2W
on passage to Arrecife, Canary Islands.
3.3.3
The fire alarm on the Autotronica Fire Detection System (see figure 4) sounded
on the bridge and engine control room (ECR) at 0324, indicating a fire on the
starboard side of the auxiliary engine room on deck 1, fire zone 4. The 4/E who
was attending to the engine room logbook, immediately called by radio the
Oiler and Motorman who were in the process of conducting a routine inspection
of the engine room, to proceed to the auxiliary engine room and investigate the
fire alarm and report any findings. A significant time discrepancy was noted
during the course of the investigation between the ships time and the
Autotronica Fire Detection System time code, a difference of 19 minutes.
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Figure 4: Autotronica Fire Detection System – Bridge Display
3.3.4
The Oiler reported “when I arrived in the main engine room I see a lot of
smoke in boiler room" (auxiliary engine room). This was confirmed by the
closed circuit television circuit (CCTV) monitor, displayed in the ECR and
witnessed by the 4/E.
3.3.5
On the bridge, the 3/O on watch, hearing the fire alarm, acknowledged the
alarm and confirmed the location. Conversations overheard on the UHF radio
by the 3/O, between the 4/E, Oiler and Motorman also alerted the bridge to the
fire. This was quickly followed with a phone call from the 4/E in the ECR to
the bridge, advising “he had a fire in the engine room, boiler room auxiliary
engine No.1” (AE1). The 4/E then proceeded to shut down the AE1, which is
located on the starboard side of the auxiliary engine room.
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Figure 5: Location of Fire (AE1 - Deck 1, Fire Zone 4)
3.3.6
During this short period of time the Oiler and the 4/E were communicating on
the UHF radio in Tagalog and not in the common language of the ship English. As the 3/O did not speak Tagalog he was unable to understand what
was being communicated and therefore unable to monitor the situation or any
progress achieved by the actions of the initial responders.
3.3.7
Once the 4/E was satisfied the fire in the auxiliary engine room was confirmed
by the Oiler, he manually activated the Marioff Hi-fog system for the affected
area covering generators No.1, 2 and 3, via the sprinkler head No.M2 (see
figure 6) by utilizing the Hi-Fog control panel (see figure 7).
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Figure 6: Location of Hi-fog sprinkler – M2 (circled in red) adjacent AE1 and AE2 generators.
Figure 7: Hi Fog Control Panel
3.3.8
The Oiler immediately took a portable fire extinguisher accompanied by the
Motorman and attempted to extinguish the fire. Due to the intense heat and
restricted visibility the two were unable to fight the fire however they were able
to contain the fire by isolating watertight doors in adjacent fire zones. On
entering the space through the forward watertight door (WTD) No.20 they
proceeded aft to close WTD No.21 before backing out of the space the way
they entered and closed WTD No.20 behind them. The Safety Officer who was
wearing a Multi ABEK3 respiratory facemask proceeded to investigate the fire
from forward to aft. On arrival at the WTD No.20 he met with the Motorman
and the Oiler who had exited the space moments prior.
3.4
Code Bravo
3
ABEK – Organic; Inorganic; Sulphur Dioxide and Ammonia vapours.
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3.4.1
The 4/E called the Chief Engineer (C/E), three minutes after the initial alarm
was activated at 0327. At this time the 3/O announced CODE BRAVO from the
public address (PA) panel on the bridge, initially this announcement failed as
the public address was not properly switched on. A second attempt was made
announcing “CODE BRAVO – boiler room, deck 1 zone 4”, and in accordance
with the Emergency Organisation Manual, this Code Bravo was repeated three
times. In addition to the Code Bravo announcement, a group paging facility is
available on the PA panel which transmits emergency messages to all recipients
with a pager. In this instance a transmission was initiated with the intention of
transmitting Code Bravo. However the initial message sent Code Red Fox,
which caused some confusion to one recipient requiring clarification. Upon
hearing the Code Bravo over the PA system, the Master proceeded to the
bridge, arriving at the same time as the Chief Officer and the Cruise Director in
order to establish Central Command.
3.4.2
Meanwhile the 3/O on the bridge had reduced the ships speed to slow ahead,
while the Refrigeration Engineer in the ECR, stopped all the engine room fans
and isolated the power supply in the vicinity of the fire, he then reported back
his actions to Central Command. Communication lines were established
between the Central Command, On Scene Command Team, Area Control Team
and Rapid Response Team by UHF radio.
3.4.3
At 0338, “the affected area was completely isolated and I evaluated the
situation again, I found it to be in a secured and safe state and I decided that
there was no need for escalating the emergency” recalled the Master. He then
announced to the guests and crew members,“we have a situation in the engine
room and all is under control, so you can all relax and I will keep you updated
as we progress this incident”. By 0345, the quick closing valves were activated
from the CO24 room, closing the fuel to AE1, AE2 and AE3 generators. The
generator AE5 was unavailable due to routine maintenance, while generator
AE6 had stopped due to overheating. The preferential trip on the main
switchboard stopped all ships ventilation, caused by the overloading of the
electrical equipment on board. At 0347 the vessel had a total loss of power. At
this point the emergency generator started automatically providing sufficient
power to operate essential emergency systems.
3.4.4
The emergency operations team based in Oslo at Fred Olsen Marine Services
were alerted to the incident by the Master at 0347 and remained on hand to
provide technical advice and support as required.
3.4.5
All Code Bravo teams were fully accounted for by 0351 and reported to Central
Command.
3.4.6
At 0440 the decision was made to shut down all four main engines moments
after main engines 2 and 3 had been reported as overheating. The vessel at this
4
CO2 – Carbon Dioxide
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point was considered navigationally safe as it adopted the status of Not Under
Command (NUC)5 due to exceptional circumstances.
3.5
Fighting the Fire
3.5.1
By 0337, 10 minutes after the announcement of the Code Bravo, 5 fire teams
were mustered in firefighting suits and breathing apparatus, forward of WTD
19 where the On-Scene Command Team had been established.
Figure 8: Actual route of firefighting teams
3.5.2
The route established to the seat of the fire, as highlighted within figure 8,
enabled all fire teams to proceed through the main engine room via WTD’s 19
and 20. Due to the location of the AE1 within the Auxiliary Engine Room,
gaining access via the Main Engine Room WTD 20, provided the shortest route
possible to reach the fire and provided a bulkhead in close proximity to offer
additional protection to the fire teams when fighting the fire.
3.5.3
In total four re-entries were made in the auxiliary engine room, all 5 teams
participated, managing to extinguish the fire by 0433, 69 minutes after initial
detection.
5
COLREGS (1972) Rule 3(f) General Definitions
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3.5.4
At 0524 after ensuring no further re-ignition of the fire, the Hi-Fog system was
stopped from the ECR control panel. However over the course of the next hour
it was determined that the vessel was slowly developing a list to port. At 0627,
through the combination of the North Easterly force 4 breeze and the build-up
of water discharged from the Hi-Fog system the vessel came to rest with a 5°
list to port.
3.5.5
At 0725 AE6 was subsequently restarted locally, followed by AE4 and AE7
ensuring adequate electrical power was restored throughout the vessel.
3.5.6
Shortly thereafter, a sounding was taken of the mid tunnel, approximately
500mm of water was recorded which provoked the starting of the emergency
bilge pump in order to remove the water and attempt to resolve the port list. At
approximately 0745 the vessel re-established an upright condition prior to
resuming passage.
3.6
Peripheral Fire Damage
3.6.1
At 0358 hotspots were found on deck 2 in cabin 2101 (see figures 10 and 11),
the location of which was immediately above the source of the fire in the
auxiliary engine room. The rapid response team conducted boundary cooling
containing the situation and preventing the vertical spread of the fire.
Figure 9: Location on Deck 2 of fire damage in Cabin 2101
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Figure 10: Cabin 2101 post boundary cooling efforts
3.7
Passenger Handling
3.7.1
On the evening of the 27th January, the vessel arrived in Tenerife in order to
disembark those passengers able to return to the UK. Despite this not being the
end of the cruise, due to the severity of the damage it was determined that those
passengers capable of flying home, were to do so. Discussions were held
between the Managers of the Boudicca, Port State and the Flag Administration,
where upon it was determined to terminate the cruise. The cruise was
advertised as a NO FLY cruise, with the passengers boarding the vessel in
Southampton and completing the cruise in Southampton, this cruise afforded
those persons who for various reasons were unable to fly, the opportunity to
participate in cruising. Of the 784 passengers on board the Boudicca, 764
passengers were repatriated to the United Kingdom by air. The 20 passengers
remaining on board, who were unable to fly, were transferred to suitable cabins
on the boat deck. Additional crew were allocated to each passenger in the event
of an emergency to ensure their safety, prior to the ship returning to the UK for
repairs.
***
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4
ANALYSIS AND DISCUSSION
4.1
Auxiliary Engine (AE1) Maintenance
4.1.1
The AE1 was last overhauled in August 2013 at 69,812 running hours which
consisted of overhaul of pistons/connecting rods, replacement of big end
bearings, piston liners, valve seats and valves of cylinder heads, crankshaft
inspection and overhaul of fuel pumps and injection calibration.
4.1.2
On the 24th January AE1 underwent maintenance at 80,503 running hours,
having been on load for the preceding 3 days. This was routine maintenance
involving, in particular, overhaul of injection valves.
4.1.3
AE1 had operated the following hours each day prior to the incident
occurrence.
Date
Running
hours
21.01.2015
17
22.01.2015
24
23.01.2015 24.01.2015 25.01.2015
23
9
3
4.1.4
Twenty-four hours prior to arrival in Cadiz, AE1 was stopped to allow the
engine time to cool down in preparation for planned maintenance. The planned
maintenance of AE1 was conducted as programed upon arrival in Cadiz, Spain.
4.1.5
On completion of the routine planned maintenance, AE1 was assessed by the
Chief Engineer to ensure all work was complete and no leaks or malfunctions
were visible on first engine start after maintenance. On completion of these
checks the engine was placed on load and coupled in parallel for 12 hours.
Normal watch routines resumed on AE1 with no abnormalities reported.
4.1.6
The 2nd Engineer (2/E) was on watch between 2000 and midnight, at watch
handover the 2/E reported that there were no abnormalities observed or alarms
related to any of the auxiliary engines. The first indication of a fire within the
Auxiliary Engine Room was received by the on watch 4/E via the fire alarm
system, reporting the following location “AE & Boilers DK – 1 STBD Zone 4”.
4.2
Mechanical Failure
4.2.1
The initial cause of the fire is known to have originated from a fracture in the
fuel oil pressure gauge supply line on AE1. The supply line fitted, fractured at
the point of connection to a hex nut (see figure 12). The line is physically
connected to a compensation device which is fitted to the supply line connected
to the manometer gauge.
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Figure 11: Point of fracture in the fuel oil pressure gauge supply line
4.2.2
The fuel supply line is situated on the forward end of AE1 behind the panel
holding the manometer pressure gauges. The fuel oil pressure gauge supply line
measures the fuel oil supply to the generator by feeding the manometer gauge,
the approximate pressure of the fuel within the line is 5 bar. The steel line is
inverted ‘Z’ shape, 6mm wide and 120mm in length, situated (see figure 13)
approximately 500mm below the top of the engine and 800mm beneath the
turbo charger. At the point of the fracture the pressurized fuel, occupied the
atmosphere surrounding the engine. The exact source of ignition cannot be
determined, however, there are various components that have a surface
temperature sufficient to auto-ignite hot fuel in vapour and liquid form within
the immediate vicinity of the fracture. Due to the proximity of the turbo charger
to the fuel oil supply line at the front of the engine, it can be concluded with a
high degree of probability that the source of ignition was provided by the turbo
charger.
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Figure 12: Fractured fuel oil pressure gauge supply line schematic and photograph post fire
4.2.3
The fire engulfed the entire front end of AE1 and spread out and above the
point of ignition, moving aft, fuelled by combustible material in the
surrounding area. On examination of the scene post fire, significant damage had
been caused to cable trays, wiring looms, AE1, AE2, damage to ancillary
equipment supplying AE3, insulation, fixtures and fittings throughout the
Auxiliary Engine Room.
Figure 13: Post incident damage to forward end of AE1
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Figure 14: Collateral damage to cable tray (left) and light fixture in vicinity of AE1 (right)
4.2.4
Within the manufacturers’ manual, a schematic of the layout of the fuel supply
line is provided. On reviewing three of the Auxiliary Engine’s fuel oil pressure
supply lines, discrepancies exist in the construction and materials used of these
supply lines. AE1 and AE2 are configured using different materials compared
with that of AE3. AE3 fuel oil pressure gauge supply line is constructed with
90ᴼ compression fittings whereas AE1 and AE2 has in a place a steel fabricated
line with compression fittings on either end as per the manufacturer’s schematic
(see figure 12). In addition AE3 has a bracket situated beneath the fuel supply
line but does not come into contact with said fuel supply line, therefore
providing no support.
4.2.5
Further, the manufacturer’s manual includes a valve with valve handle on the
schematic. Although the valve is present the handle used to control the supply
of fuel to the pressure gauge is missing on all three auxiliary engines. These
discrepancies do not appear to have had any measurable impact on the
performance of the fuel oil pressure gauge supply line prior to the incident.
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Figure 15: Fuel oil pressure gauge supply lines discrepancies (left to right AE2, AE3 and AE3)
Figure 16: Fuel oil pressure gauge supply lines on AE1, 2 and 3 indicating missing valve handle
4.2.6
In November 2014 the vessel underwent a thermal survey on all auxiliary
engines by Thermo Protection Temperaturanalyse who highlighted a number of
areas that had surface temperatures in excess of 220°C. The report was received
by the technical managers in December 2014 and upon receipt, immediately
instructed the vessel’s engineers to commence fabrication of insulation
protection of those areas identified within the report. At the time of the
incident, fabrication of insulation protection on AE1 had not commenced.
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4.2.7
The thermal survey concluded that AE1 in vicinity of the fuel oil pressure
gauge supply line and turbo charger located towards the rear of the engine had
five areas identified via thermal imagery as having a high temperature in excess
of 220°C6.
4.2.8
At the time of ignition AE1 was using heavy oil fuel, which has a typical
flashpoint range of between 65~80°C and a typical minimum auto-ignition
point of 400°C. Figure 18 identifies the precise surface temperature of the turbo
charger whilst under load. As seen on the thermal image the surface
temperature recorded ranges from 22.9°C to 234°C. The two areas, SP1 and
SP2 highlighted by a red circle have a recorded temperature of 404.8°C and
401.5°C respectively.
Figure 17: Photo (left) of AE1 turbo charger in vicinity of fuel oil pressure gauge supply line and thermal
image (right)
4.2.9
The insulation surrounding the exhaust gas turbo charger identified in figure 19
appears visually adequate7, however when compared to the thermal image, it
clearly detects gaps within the insulation potentially exposing the high
temperature surface of the exhaust to the atmosphere.
6
High Temperature defined within MSC.1/Circ.1321 Guidelines for Measures to Prevent Fires in EngineRooms and Cargo Pump-Rooms
7
“Dry type turbo chargers, if installed, should be completely insulated, as far as practicable, to prevent the
existence of high temperature surfaces.” MSC.1/Circ.1321 Guidelines for Measures to Prevent Fires in
Engine-Rooms and Cargo Pump-Rooms: Chapter 2, paragraph 1.1.4
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Figure 18: Photo (left) of AE1 turbo charger exhaust in vicinity of fuel oil pressure gauge supply line and
thermal image (right)
4.2.10
The thermal image of the bearing housing of the AE1 turbo charger had a
maximum-recorded temperature of 445.3°C. The surface of the turbo charger
had no insulation or spray shields to prevent flammable oil coming into direct
contact with high temperature surfaces.
Figure 19: Photo (left) of AE1 turbo charger bearing housing in vicinity of fuel oil pressure gauge supply line
and thermal image (right)
4.3
Hi-Fog Operation
4.3.1
The Hi-Fog zone flooding protection system for machinery spaces is activated
when one or more of the release buttons is pressed, opening corresponding
section valves, allowing water to the activated section. Water flow in the
system results in a signal that is indicated at the Control and Indication Panel.
4.3.2
System control panels are located on the bridge and in the ECR, once activated
the decreased pressure flow within the system will activate the relay control
unit that will trigger the pump unit to start. The electric motors are started in
sequence with a few seconds between each to prevent excessive peak loads.
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4.3.3
The Hi-Fog system is fed from a high-pressure tank which is fed from technical
water tanks. When the system is activated the level in the high-pressure tank
will drop, activating two feed pumps from the technical tanks to resupply the
high-pressure tank with seawater via the seawater inlet valves.
4.3.4
The Hi-Fog system was activated in order to extinguish the fire and provide a
blanket of water in the vicinity of AE1. The system was activated by the onwatch engineer on the control panel situated in the ECR, in accordance with
emergency procedures. Two hours later the Hi-Fog system was stopped having
established that the fire had been extinguished.
Button manually activated by
the engineer on duty upon
confirmation of fire.
Figure 20: HI Fog Sprinkler System Panel
4.3.5
Due to the developing list, which was the first indication the vessel had not
restored all systems, it was determined that the Hi-Fog system had continued to
operate for 1 hour 14 minutes after the point at which it was assumed it had
been stopped. The estimated water discharged into the space during the course
of the systems operation was in the region of 80m3, which was collected in the
bilge of the chilling plant and water generation room, aft of the auxiliary engine
room that subsequently drained into the tunnel room (tank top).
4.3.6
A Marioff technician, instructed to determine the cause of the system not
operating as required, found that at some point during the incident the manual
emergency start button had been activated on the bridge panel which starts all
high pressure pumps, feed water pumps and overrides the pump units technical
tanks high level switch. This resulted in the technical tanks to overflow despite
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the reset switch on the ECR control panel being pressed; continuous operation
was maintained until the point at which the emergency start button was reset on
the bridge control panel.
4.3.7
It may have been apparent to the operator on the bridge if the lamp, indicating
the switch was activated had not been faulty, resulting in a delay in switching
off the breakers to the system to stop the Hi-Fog system from operating.
4.3.8
Once acknowledged as being the root cause of the 5º list to port, the remaining
water was pumped from the bilge restoring the upright condition of the vessel
via the onboard emergency bilge pumps.
Figure 21: Bridge – Emergency Start Button
4.4
Command and Control
4.4.1
From receipt of the alarm being raised of a fire within the Auxiliary Engine
Room, specifically AE1, the 4/E on watch carried out initial reactions as
required, in a timely and controlled manner by instructing the Motorman and
Oiler to procced to the location identified on the Autotronica Fire Detection
System and investigate the source of the alarm. The Oiler and Motorman
conducted a compartment search in accordance with the Chief Engineers
Standing Orders and identified the exact location and severity of the fire, which
in turn enabled the 4/E to inform the Command Team mustered on the bridge.
4.4.2
Successful command and control of any emergency situation relies on the
processing and understanding of information quickly and succinctly by all
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members of the emergency organisation. In this instance, in the early stages of
determining the severity of the fire, conversations between the Oiler and
Motorman, being conducted on the UHF open frequency was not in the
common language of the vessel. The 3/O was therefore not in a position to
coordinate and control events prior to the emergency organisation establishing
itself.
4.4.3
It was determined during the interview that the OOW was unfamiliar with the
correct operation of the PA system with regards to which areas the Code Bravo
announcement should be made (i.e. crew areas, guest areas). Initially the
broadcast was made but immediately after the announcement realised that the
incorrect button had been pressed in order to transmit the broadcast. A lack of
familiarity is apparent with the operating procedures of fundamental safety
equipment designed to expedite a response to an emergency.
4.4.4
An additional emergency procedure exists on board to ensure the Emergency
Organisation establishes itself in the quickest possible fashion. Aside from the
public address (PA) system, the vessel has a pager system sending a pre-set
signal to alert all crew with a pager the appropriate emergency code. The
system on board the vessel sent the unrecognised emergency signal ‘Red Fox’
instead of Code Bravo.
4.4.5
During the course of the investigation, it became apparent that Autronica Alarm
System was not synchronized with the ships clock, which being the basis for
time on board, meant that multiple systems were recording the same event but
displaying a different time. In one case there was a 19 minute discrepancy
between the ships clock and the Autronica System. When conducting an
investigation and evaluating the evidence from different sources, it is vital that
the time each event occurs is accurate in order to piece the events back together.
4.4.6
During the initial investigation phase, the Oiler and Motorman were able to
proceed from forward to aft, unobstructed through WTD 20, continuing aft to
WTD 21, which they closed prior to backing out of the space via WTD 20,
closing it behind them. Both these doors are classified as category B8 watertight
doors. This door should be closed, but left open for the length of time personnel
are working in the adjacent compartment. The watertight integrity of the vessel
relies on the correct operation and adherence to WTD policy, further, the
containment of smoke is paramount in order to avoid smoke ingress to adjacent
compartments potentially rendering them unattainable.
8
A watertight door that fulfils the technical requirements in SOLAS regulations II-1/13.5.1 to 13.5.3 and
13.6 (previous SOLAS regulations II-1/15.6.1 to 15.6.4), which also includes the requirements in
paragraph 7 of SOLAS regulation II-1/13 (previous SOLAS regulation II-1/15), and may be opened
during navigation when work in the immediate vicinity of the door necessitates it being opened, according
to SOLAS regulation II-1/22.3 (previous SOLAS regulation II-1/15.9.2). The door must be immediately
closed when the task which necessitated it being open is finished.
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5
CONCLUSIONS
5.1
The routine maintenance conducted on AE1 does not reveal any mechanical
failure of the fuel oil gauge supply line prior to the fire. Due to the varying fuel
oil supply lines on board, determining what may have caused the fuel oil supply
line to fracture cannot be determined by simply comparing fuel oil supply lines
on other engines with similar operational hours. During the course of the
investigation it has been determined that the maintenance and inspection
conducted on AE1 refrained from disturbing, disconnecting or tightening of the
compression fitting of the fuel oil pressure gauge supply line.
5.2
In conclusion, the steel fuel oil pressure gauge supply line may have suffered
from fatigue failure through engine-generated vibrations causing the steel pipe
to work-harden resulting in the supply line to become brittle and therefore more
susceptible to fracture in vicinity of the compression fitting. It remains
inconclusive whether fatigue was responsible for the material failure of the pipe
however it should be recognised that AE1 had 4,345 more running hours9 than
the remaining Auxiliary Engines at the time of the casualty.
5.3
The fracture caused the fuel to be sprayed upwards and in the vicinity of the hot
surface generated by the turbo charger. If the thermo-protection insulation been
fabricated in the vicinity of the turbo charger, thereby providing a barrier to
prevent fuel in vapour and liquid form from coming into contact with the
exposed hot surfaces of the turbo charger, it could be concluded with a high
degree of probability that the fuel in vapour or liquid form would not have had
sufficient attributes required to ignite.
5.4
The initial reaction by the crew in establishing a timely emergency response
should be commended. The instinct and professionalism exhibited by the crew
was instrumental to the successful outcome and proved effective in containing
the spread and extinguishing the fire without casualties.
5.5
The operation of the Hi-Fog system was well understood by the crew in regard
to its activation. However, it was determined after the fire had been
extinguished, whilst in the process of restoring emergency systems that the HiFog remained in operation. Due to a lack of understanding of the electrical
control system, by activating the manual emergency start in conjunction with a
faulty bulb masking the indication that the system was in operation, the system
never restored fully which consequently resulted in a 5° port list.
5.6
Despite the unrecognised emergency pager signal transmitting to senior safety
critical crew, it did not seem to delay the response of the emergency
organisation. However, this did indicate to the investigator that the pager
9
The Owners acknowledge that the difference in running hours between the auxiliary engines is planned
to ensure the overhaul of all auxiliary engines occur at different times.
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system had not been used during any drill prior to the 24th January or else this
unrecognised signal would have been identified by the emergency organisation.
5.7
The Company continued to prioritise passenger safety and well-being up until
repatriation to the passenger’s place of residence. Those passengers who were
unable to fly due to personal circumstances were catered for accordingly and
without detriment to their health or safety. The Company worked with the
relevant authorities to ensure the relevant legislative requirements were in place
to the satisfaction of the flag Administration.
***
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6
RECOMMENDATIONS
Recommendations for the operator:
6.1
Consider fabricating insulation protection for those areas identified within the
Thermo Protection Temperaturanalyse report. In addition, it is recommended
that thermal surveys be conducted at regular intervals and on completion of any
maintenance or repair of equipment that has been carried out, to ensure that the
insulation material has been properly reinstalled or replaced.
6.2
The fuel oil supply lines fitted to the auxiliary engines should meet the
manufactures recommended arrangement and only be constructed using the
appropriate and approved material and/or components.
6.3
Review the safety management system to ensure it contains specific procedures
to identify vibration fatigue. Further, inspect all fuel lines on all auxiliary
engines on all vessels in the fleet to ensure where practicable, all lines are
secured in a manner to eliminate vibration where possible.
6.4
Ensure the operating procedures of the Marioff water mist suppression system
is fully understood by all members of the emergency response team to ensure
effective operation and system restoration on completion of use.
6.5
Ensure all members of the bridge watch team are competent in the safe
operation of all bridge equipment, particularly equipment required for
emergency response procedures.
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7. ACTIONS TAKEN
7.1
All Officers and crew have been reminded that the language of the ship is
english and of the importance that this is enforced, especially on the bridge,
engine control room during all emergency situations.
7.2
A review of the vessel’s departure checklist has been updated to include a time
check which is to be conducted on all data recording devices and clocks prior to
vessel departure from the berth.
7.3
The Owners have implemented a procedure to ensure all WTD’s are operated
and monitored in accordance with the vessel’s stability booklet, DNV Class
direction and the BMA bulletin No. 96 (Maintaining Passenger Ships WTD’s
Open During Navigation).
7.4
A review of the paging system to ensure the code which is transmitted to senior
safety critical crew reflects the nature of the emergency and sends the
appropriate pre-planned message.
7.5
All Officers of the Watch to have reviewed and understood the operating
procedures of the PA system with particular regard to making emergency
announcements.
7.6
Operating instructions are now located in the vicinity of both Hi-Fog panels and
a review of the standard operating procedures in the use of Hi-Fog operating
system has been conducted.
7.7
All fuel lines with similar configurations have been inspected on all vessels to
ensure fuel oil pressure gauge supply lines are sound and free from vibration.
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LIST OF APPENDICES
I.
Hi-Fog post incident report
II.
Auxiliary Generator Front End Schematic (MaK 6M20 1020kW)
III:
Additional photos
***
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Appendix I: Hi-Fog post incident report
Figure 22: Hi-Fog post incident report (page 1)
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Figure 23: Hi-Fog post incident report (page 2)
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Appendix II: Auxiliary Generator Front End Schematic (MaK 6M20 1020kW)
Figure 24: Front End MaK 6M20 Auxiliary Engine
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Appendix III: Additional Photos
Figure 25: Mid tunnel tank top flooding (Frame 40-60)
Figure 26: Fire Control Plan
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Figure 27: Fractured fuel oil pressure gauge supply line
Figure 28: WTD No. 20 looking aft into the Main Engine Room
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